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2440 IYANNOUGH ROAD - Health
2440 Iyanri6ugh Road/R6tite 132 West Barnstable A = 246 - 042.� / U TOWN OF BARNSTABLE LOCATIONo� ® SEWAGE 04;P_ /00/ VILLAGE Its e ASSESSOR'S MAP.&PARCEL !ZZ INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) /�, 3 NO.OF BEDROOMS 5 OWNER PERMIT DATE: o<— 7--', COMPLIANCE DATE: Separation Distance Between the: i Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility Of any wells exist ori` site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) / Feet FURNISHED BY 1-r7, 6 4v l'o 34 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Rppl Latlon for Disposal §�pstrm Construrtion 3pPrmit Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System ,Individual Components Location Address or Lot N ��O,2�/Y.dd!41��/i Owner's Name,Address,and Tel.No. Assessor's Map/Parcel o7 O !!i �d/• Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building �� �• No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3® gpd Design flow provided gpd Plan Date e�� Number of sheets J Revision Date Title Of Size of Septic TankIleX�f�l�'�r ��G'4 L94 ype of S.A.S 1-100 Z1.A 4d ' Description of Soil 4tO Nature of Repairs or Alterations(Answer when applicable) J e'6' Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of H lth. 7 Signed Date 7 �/ Application Approved by Date 6 ! / Application Disapproved by Date for the following reasons Permit No. , Date Issued h - - - -------------- - } Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes application for bispo'saf ,4pstrin Construction jhrmit Application for a Permit to Construct( ) Repair/Up de( ) Abandon( ) El Complete System Individual Components Location Addr'ess-or Lot NqAs f-o l�j�/y/. �'� Owner's Name,Address,and Tel.No. Assessor's Map/Parcel o7 �•�'./pl l 1. �� ✓// Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building 4' C;?% r No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 3 O gpd Design flow provided �' 3 gpd Plan Date 45, Number of sheets ' Revision Date Title Size of Septic Tank�X��3�NG' Description of Soil .J3G6Gt Ov car Nature of Repairs or Alterations(Answer when applicable) J'�� �1�i�/✓ Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of He Ith. Ir Signed Date G `7 r Application Approved by Date Application Disapproved by Date for the following reasons Permit No. 21 Date Issued --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS &rtificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( 19<0, Upgraded( ) Abandoned( )by �" ,OW ee180 f�! J'E�T�C J'vC - at DV�r�e:�P� 00 'e S"c"onstructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit NQ9D/ _ ) dated Installeris?� 4�D�U� Designer #bedrooms 3 Approved design flo gpd The issuance of this permit shall not fie construed as a guarantee that the syste wil�functlj'," n i. e Date f�/ Inspector --------------------------------I----------------------------------------------------------------------------------------------_�--- No '// / J THE COMMONWEALTH OF MASSACHUSETTS --x Fee N0 PUBLIC HEALTH DIVISION- BARNSTABLE, MASSACHUSETTS Disposal *pBtrnt Construction 3permit Permission is hereby granted to Construct( ) Repair Upgrade( ) Abandon( ) System located at C;rT.TD �y��y�r Oy�y �iC.� ji(/ �j�✓ and as described in the above Application for Disposal System Construction Permit. The ap licant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed/within three years of the date of this permit. Date I( l Approved by V - r w Town of Barnstable IKE?4 Regulatory Services Thomas F.Geiler,Director NAM. Public Health Division �6 9. Thomas McKean, Director 200 Main Street, Hyannis,-'VIA 02601 Office: 508- 62-464-4 Fax: 508-790-6304 Date: %p 1Z � Sewage Permit#��/ � Assessor's Map/Parcel ?� Installer&Designer Certification Form Designer: 0, � Installer: ._j A �,���U Address: i�J t �I�GG '1 Address: l On �,� was issued a permit to install a fie) (inAr) septic system at based on a design drawn by (address) dated (designer) I certify that the septic system referenced above vas installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution, box and/or s is tank. Strioout (if required) was inspected and the soils were found satisfactory ` I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or anv vertical relocation of any component of the septic system) but in accordance with State& Local T1- '-Lions. Plan revision or certified as-built by designer to.follow. Stripout(if r- acted and the soils were found satisfactory. �H OF444,;s r DAVID 9c%1, B. . nstaller's Signature} MASOV C> Q65 0 IS P esi� er s Signature} PLEASE RETURN TO BARNSTABLE PUBL._ J __C',fE OF COMPLIANCE WILL. NOT BE ISSUED UN i IL rsu 1 n i U16 r ORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. g:wffrce fonnMdesipercortification fonn.doc i _ p � A ' ilia Town of Barnstable P# De artitnent of Re ° . � F P gulatory Services � Public Health Division b (� Date se79� J2 in Street,Hyannis MA 02601 Date Scheduled Ti'ma . Fee Pd. L(' Soil Suitability Assessment for Se e Disposal Performed•By:. Witnessed By: I"allon Address LOCATION&GENERAL L FORMATION , 9yk,06 0dO*'OU4'J1 XA&P Owner's Name Address Assessor's Map/Parcel:' O•�ax Engineer's Name Ae Apo'a, NEW CONSTRUCTION REPAIR 7 Telephone# Land Use- 7 Slopes(%) Surface Stones Dletanecs fhom: Open Water Body ft _possible Wet.Area ft Drinking'Water Well . ft Dralhage Way�—ft property Line • ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&pare tests,locate wetlands in proximity to holes) TA Parent material(geologic) Depth to Bad,-Oak Depth to Groundwater. Standing Water In Hole: Weeping flan Pit Faoa Pstimated Seasonal Figh Oroundwater DETERMINATION FOR SEASONAL-HIG WATER TABLE Method Used: Depth Observed standing In obs.hole: DeA to weeping from side of obs.hole: In. Depth110 evil Inottlee: ReadingItL Index Well Or --� - bL Oroundwater Adjustment �l Dat°s Index Well leYal___ _ Adj.factor Adj.prnundwuter Leval,, _ 1 Observation PERCOLATION TEST Hole# l� TIme at 9" Depth of Perc Time at 6" Start Pre-soak Time @ Time(9"-6") End Pre-soak Rate Miu./Iuch Site Suitability Assessment: Site Passed Sine Felled: Addldomal Testing Needed(Y/N) Original: Public Health Division Obse6n1lon Hole Data To Be Completed on Back — ***If percolation testis to be conducted within 100' of wetland,you must first notify tile. Barnstable Conseirvation Division at least one(1)week;prior to beginning. Q:ISEPTICIPERCFORM.DOC r�[ DEEP.OBSERVATION HOLE LOG -Hole# Depth from Soil Horizon Soil Texture Shcl Color Boll. Other Stuface(in.) / (USDA) (Munsell) Mottling (Structure,Stoned;Boulders. r at tc cy,%t3rivall of `a,� Ap !A er 7Z, DEEP OBSERVATION HOLY LOG Hole# Depth from Boll Horizon Soil Texture Soil Color Soil Other. Surface(in.) (USDA) (Mudsell) Mottling (Structure,Stones,Boulders. Consistmov,%Gravell DEEP OBSERVATION HOLE LOG Hole,# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Muusell) Mottling (Structure,Stones,Boulders. Consistancy.%G DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Solt Color Boil Other Surface(in.) (U$DA) (Munsell) Mottling (Structure,Sloiles.Boulders. Consistoncv. i j Flood Insurance Rate Map: Above 500 year Mood boundary No—/Yes Within 500 year boundary, No YCA Within 100 year flood boundary No., Yes De th of aturally Occurrine PeryiortA Material Does at least four feet of naturally occurring pery ou rial exist in all al'eas observed thrpughout the area proposed for the soil absorption system? If not,what is the depth of hater lly occurring pery us matorlal?—m=l -_ Certification I•certify that on �® y (date)I have passed the soil evaluator examination approved by the Department of Envir mental Protection and that the above analysis was performed by me consistent with . the required training,oxDDruguarij experience described in 10 CMR 15.017. Signat e Dat QAR EFTICWERCFORM.DOC �� IL TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date a" ' �" Time: In Out Owner ` ( Tenant Address �� & Address W f� �— Complia a Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities 6. Heating Facilities a� 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use _ 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal 3 17.Temporary Housing N � 0-0 18. Driveway Width 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms Z2 Number of Vehicles Allowed (max) Number of Persons Allowed (max) Person(s) Interviewed Inspector If Public Building such as Store or Hotel/Motel specify here i ` TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date a _ Time: In Out Owner 10 1�'� Tenant '. Address �6 13 Address 9 L-f q n (3 W Complia ce Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities 6. Heating Facilities } 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal 17. Temporary Housing 18. Driveway Width 19. Number of Tenants Observed 3 PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms Number of Vehicles Allowed (max) Number of Persons Allowed (max) 1. : Person(s) Interviewed Inspector If Public Building such as Store or Hotel/Motel specify here I TOWN OF BARNSTABLE Approved.MLD Cert. � BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date 3 lC, \ O !e� Time: In \\,C0 Out \: 16 Owner T N o NVA-S -t Ce I e D etj YIAt`n u1 Tenant '�� \�V.�-✓� LGA i S �y Address K tyc,& 0 Address 2 o,A♦.l ouCcXA (L�, Compliance Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities l 1 (9b 6. Heating Facilities A S F N w 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities V 10. Curtailment of Service ✓ �� 11. Space and Use (L 12. Exits , Vj 13. Installation and Maintenance of Structural / Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 'j 1E Q 4. 16. Sewage Disposal R-t V AJ 17. Temporary Housing /vim 18. Driveway Width 19. Number of Tenants Observed 2— PART II 37. Placarding of Condemned Dwelling; C> c, I L 0 Removal of Occupants; Demolition 1 0 Number of Bedrooms 3 I�� Number of Vehicles Allowed (max) Number of Persons Allowed (max) S 1$v Person(s) Interviewed Inspector S• 17 If Public Building such as Store or Hotel/Motel specify here TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date 3 I o I O Time: In 11:UU Out Owner �\1 t�r n� a t Ce 1{ 4 U Zvi V- k t��t wt Tenant 1n��1-y. fL v7 Address 2 U � �"I ti\ l..�u0 t)/, �� Address 2 �J �ti rvSitihL� r V� G �P, b �n+ '14 Lt Compliance Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities ; 3. Bathroom Facilities Y 4. Water Supply V-- 5. Hot Water Facilities (✓ , 1 �U 6. Heating Facilities kAj 7. Light.ng and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service ! Ud ,P 11. Space and Use 12. Exits ,,✓ 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents ✓ 15. Garbage and Rubbish Storage and Disposal �C ' �A 16. Sewage Disposal ,/ t2 t VA-1 17. Temporary Housing N/`c 18. Driveway Width 19. Number of Tenants Observed a 2- l Yr PART 11 37. Placarding of Condemned Dwelling; C. Removal of Occupants; Demolition Number of Bedrooms I Number of Vehicles Allowed (max) Number of Persons Allowed (max) Person(s) Interviewed4MLl Inspector S If Public Building such as Store or Hotel/Motel specify here f 11�4� Z F Th1E tp� The Town of Barnstable MRNMBUE, * Office of Town Manager v� MAM ��� 367 Main Street Hyannis MA 02601 www.town.barnstable.ma.us Office: 508-862-4610 John C. Klimm, Town Manager Fax: 508-790-6226 Email: john.klimmp_town.barnstable.ma.us MEMORANDUM TO: Tom McKean, Director Health Dept. FR: John C. Klimm, Town Manager DT: March 19, 2008 RE: Public Notification of Response Action Outcome Statement Threat of Release, 2240 Iyanough Road West Barnstable,MA DEP Release Tracking No. 4-20462 Tom, for your information I am sending a copy of a letter from Clean Harbors on the subject matter mentioned above. Thank you. JCK: smo Attachment E CleanHarbor3TO ti 0' G �n 4L ENVIRONMENTAL SERVICES® 'Q$Clean Harbors Environmental Services,Inc. MAR 14 P 4 :06 42 Longwater Drive Norwell,MA 02061-9149 Phone:781-792-5000 Fax:781-792-5938 www.cleanharbors.com March 7, 2008 John Klimm Town Manager 367 Main Street Barnstable, MA 02601 Re: Public Notification of Response Action Outcome Statement Threat of Release, 2240 Iyanough Road W. Barnstable,MA DEP Release Tracking No.4-20462 Dear Sir/Madam On behalf Cape Code Community College, Clean Harbors Environmental Services, Inc. (CHES) is submitting this notification and the attached copy of the Release Notification Form (RNF) as part of the public involvement process required by the Massachusetts Contingency Plan (MCP, 310 CMR 40.0000). Local officials have the right to request.additional public involvement activities under 310 CMR 40.1403 (9). The conclusions of the Response Action Outcome Statement are presented below. On April 25, 2007, at approximately 4:00 PM, a Threat of Release condition was identified at the property located at 2240 Iyanough Road in West Barnstable. The Threat of Release was associated with an electrical transformer located in the North Building of CCCC, and consisted of a transformer oil stain on the concrete floor around a portion of the transformer. The oil was subsequently determined to contain PCBs.No impact to soil or groundwater occurred. In response to the Threat of Release, CCCC contracted CHES to perform an IRA that included the use of absorbents, cleaning of surfaces within the transformer area, and collection of a PCB wipe sample from the release area. In addition,the cause of the stain on the floor was repaired. Because the impacted area was cleaned*and the wipe sample collected from the affected area indicated that no detectable PCB concentrations were present following the IRA, background or pre-existing conditions were restored and a Permanent Solution and a level of No Significant Risk were achieved. As such, the requirements for a Class A-1 RAO Statement have been met,and no further response actions are required. RTN 4-20462 March 7,2008 Page 2 of 2 This report is available for review at the Southeast Regional Office of the Massachusetts Department of Environmental Protection (20 Riverside Drive, Lakeville MA 02347), or by contacting John Lebica (contact information on attached copy of Release Notification Form). No action other than the receipt of this letter is necessary by your office. T 0 W G. B!F '08 MAR 14 P 4 :0 6 Sincerely, 0J Peter Klausmeyer Field Inspector cc: Town of Barnstable Board of Health 200 Main Street Hyannis, MA 02601 Project File EO1564396 Attachment: copy of RNF Clean Harbors Environmental Services,Inc. FORM30 &w HOBBS&WARREN TM THE COMMONWEALTH OF MASSACHUSETTS BOARD OF H TH �. CITY TOWN W � b 9 /� DEP TMENT e"u,^ _ �'1 A bOI--Go I ADDRE81S GSM sve y`0W ' I TELEPHONE o W� Address ° I — Occupant_ ^^ 1� Floor Apartment No. No.of Occupants No.of Habitable Rooms No.Sleeping Rooms_ No.dwelling or rooming units No.Stories Name and address of owner-,;" l� -0 Ij�fI Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Lighting: STRUCTURE INT. Hall,Stairway: , Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 11220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room Bedroom 1 Bedroom 2 (J ` Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.: St As, Flues,Vents feties: Kitchen Facilities S' k S 'Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION MfJRT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES OF PE U INSPECTOR TITLE " F DATE TIME A._ A.M. THE NEXT SCHEDULED REINSPECTION P.M. ' 3 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions,when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs.of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B)and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish,filth or other causes of sickness which may provide a food source or harbora e for rodents, insects or other pests 9 9 or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. y14D us �. r E• leanHarborS ENVIRONMENTAL SERVICES® Clean Harbors Environmental Services,Inc. 42 Longwater Drive Norwell,MA 02061-9149 Phone:781-792-5000 Fax:781-792-5938 www.cleanharbors.com March 7, 2008 John Klimm <i 47 Town Manager C) 367 Main Street Barnstable, MA 02601 - CD Re: Public Notification of Response Action Outcome Statement r Threat of Release, 2240 Iyanough Road W.Barnstable,MA DEP Release Release Trackin�No. 4-204624-20462 Dear Sir/Madam On behalf Cape Code Community College, Clean Harbors Environmental Services, Inc. (CHES) is submitting this notification and the attached copy of the Release Notification Form (RNF) as part of the public involvement process required by the Massachusetts Contingency Plan (MCP, 310 CMR 40.0000). Local officials have the right to request additional public involvement activities under 310 CMR 40.1403 (9). The conclusions of the Response Action Outcome Statement are presented below. On April 25, 2007,at approximately 4:00 PM, a Threat of Release condition was identified at the property located at 2240 Iyanough Road in West Barnstable. The Threat of Release was associated with an electrical transformer located in the North Building of CCCC, and consisted of a transformer oil stain on the concrete floor around a portion of the transformer. The oil was subsequently determined to contain PCBs.No impact to soil or groundwater occurred. In response to the Threat of Release,CCCC contracted CHES to perform an IRA that included the use of absorbents, cleaning of surfaces within the transformer area, and collection of a PCB wipe sample from the release area. In addition, the cause of the stain on the floor was repaired. Because the impacted area was cleaned and the wipe sample collected from the affected area indicated that no detectable PCB concentrations were present following the IRA, background or pre-existing conditions were restored and a Permanent Solution and a level of No Significant Risk were achieved. As such, the requirements for a Class A-1 RAO Statement have been met, and no further response actions are required. RTN 4-20462 March 7,2008 Page 2 of 2 This report is available for review at the Southeast Regional Office of the Massachusetts Department of Environmental Protection (20 Riverside Drive, Lakeville MA 02347), or by contacting John Lebica (contact information on attached copy of Release Notification Form). No action other than the receipt of this letter is necessary by your office.. Sincerely, Peter Klausmeyer Field Inspector cc: Town of Barnstable Board of Health 200 Main Street Hyannis, MA 02601 Project File EO1564396 Attachment: copy of RNF Clean Harbors Environmental Services,Inc. 1 Massachusetts Department of Environmental Protection `Bureau of Waste Site Cleanup BWSC103 RELEASE NOTIFICATION $ NOTIFICATION Release Tracking Number RETRACTION FORM 4❑ - 0462 Pursuant to 310 CMR 40.0335 and 310 CMR 40.0371 (Subpart C) A. RELEASE OR THREAT OF RELEASE LOCATION: 1. Release Name/Location Aid: Cape Cod Community College 2. street Address: 2240 lyanough Road 3. City/Town: West Barnstable 4. ZIP Code: 02668-1599 5.UTM Coordinates: a. UTM N: 4616377 b. UTM E: 388804 B. THIS FORM IS BEING USED TO: (check one) © 1. Submit a Release Notification ❑ 2. Submit a Revised Release Notification ❑ 3. Submit a Retraction of a Previously Reported Notification of a release or threat of release including supporting documentation required pursuant to 310 CMR 40.0335 (Section C is not required) (All sections of this transmittal form must be filled out unless otherwise noted above) C. INFORMATION DESCRIBING THE RELEASE OR THREAT OF RELEASE(TOR): 1. Date and time of Oral Notification, if applicable: 04/25/2007 Time: 04:10 ❑ AM PM mm/dd/yyyy hh:mm 2. Date and time you obtained knowledge of the Release or TOR: 04/25/2007 Time: 04:00 ❑ AM PM mm/dd/yyyy hh:mm 3. Date and time release or TOR occurred,if known: Time: ❑ AM ❑✓ PM mm/dd/yyyy h h:m m Check all Notification Thresholds that apply to the Release or Threat of Release: (for more information see 310 CMR 40.0310-40.0315) 4. 2 HOUR REPORTING CONDITIONS 5. 72 HOUR REPORTING CONDITIONS 6. 120 DAY REPORTING CONDITIONS ❑ a. Sudden Release a. Subsurface Non-Aqueous a. Release of Hazardous ❑ Phase Liquid(NAPL)Equal to ❑ Material(s)to Soil or Q b. Threat of Sudden Release or Greater than 1/2 Inch Groundwater Exceeding c. Oil Sheen on Surface Water ❑ b. Underground Storage Tank Reportable Concentration(s) (UST)Release b. Release of Oil to Soil ❑ d. Poses Imminent Hazard ❑ Exceeding Reportable e. Could Pose Imminent ❑ c. Threat of UST Release Concentration(s)and Affecting Hazard Ei More than 2 Cubic Yards d. Release to Groundwater ❑ f. Release Detected in near Water Supply C. Release of Oil to Private Well ❑ Groundwater Exceeding e. Release to Groundwater Reportable Concentration(s) ❑ g. Release to Storm Drain ❑ near School or Residence d. Subsurface Non-Aqueous ❑ h. Sanitary Sewer Release ❑ f. Substantial Release Migration ❑ Phase Liquid(NAPL)Equal to (Imminent Hazard Only) or Greater than 1/8 Inch and Less than 1/2 Inch Revised:02/10/2006 Pagel of 3 Massachusetts Department of Environmental Protection Bureau of Waste Site Cleanup BWSC103 RELEASE NOTIFICATION & NOTIFICATION Release Tracking Number RETRACTION FORM 4❑ - 20462 Pursuant to 310 CMR 40.0335 and 310 CMR 40.0371 (Subpart C) C. INFORMATION DESCRIBING THE RELEASE OR THREAT OF RELEASE(TOR):(cont) 7. List below the Oils(0)or Hazardous Materials(HM)that exceed their Reportable Concentration(RC)or Reportable Quantity (RQ)by the greatest amount. O or HM Released CAS Number, O or HM Amount or Units RCs Exceeded,if if known Concentration Applicable(RCS-1,RCS-2, RCGW-1,RCGW-2) PCB oil O < 1 LBS 8. Check here if a list of additional Oil and Hazardous Materials subject to reporting is attached. D. PERSON REQUIRED TO NOTIFY: 1. Check all that apply: El a,change in contact name b.change of address E] c. change in the person notifying 2. Name of Organization: Cape Cod Community College 3. Contact First Name: John 4. Last Name: Lebica 5. street: 2240 lyanough Road 6.Title: Director, Facilities Management 7. City/Town: West Barnstable 8. State: MA s. ZIP Code: 02668-1599 10. Telephone: (508) 362-2131 11.Ext.: 4177 12. FAX: (508) 375-4048 o13. Check here if attaching names and addresses of owners of properties affected by the Release or Threat of Release, other than an owner who is submitting this Release Notification(required). E. RELATIONSHIP OF PERSON TO RELEASE OR THREAT OF RELEASE: Q 1. RP or PRP F] a. Owner ❑ b. Operator c. Generator d. Transporter Q e. Other RP or PRP Specify: 2. Fiduciary,Secured Lender or Municipality with Exempt Status(as defined by M.G.L.c.21 E,s.2) 3. Agency or Public Utility on a Right of Way(as defined by M.G.L.c.21 E,s.50)) 4. Any Other Person Otherwise Required to Notify Specify Relationship: Revised:02/10/2006 Page 2 of 3 I Massachusetts Department of Environmental Protection Bureau of Waste Site Cleanup BWSC103 RELEASE NOTIFICATION & NOTIFICATION Release Tracking Number RETRACTION FORM 4❑ _ 20462 Pursuant to 310 CMR 40.0335 and 310 CMR 40.0371 (Subpart C) F. CERTIFICATION OF PERSON REQUIRED TO NOTIFY: 1 I,John Lebica ,attest under the pains and penalties of perjury(i)that I have personally examined and am familiar with the information contained in this submittal,including any and all documents accompanying this transmittal form,(ii)that,based on my inquiry of those individuals immediately responsible for obtaining the information,the material information contained in this submittal is,to the best of my knowledge and belief,true,accurate and complete,and(iii) that I am fully authorized to make this attestation on behalf of the entity legally responsible for this submittal. 1/the person or entity on whose behalf this submittal is made am/is aware that there are significant penalties,including,but not limited to, possible ' r' o t,for willfully submitting false,inaccurate,or incomplete information. 2. BY 3. Title: Director, Facilities Managerr Signature 4. For: C e Cod Community College 5. Date: oZ (Name of person or entity recorded in Section D) m dd/yyyy ❑ 6. Check here if the address of the person providing certification is different from address recorded in Section D. 7. Street: 8. City/Town: 9. State: 10. ZIP Code: 11. Telephone: 12.Ext.: 13. FAX: YOU ARE SUBJECT TO AN ANNUAL COMPLIANCE ASSURANCE FEE OF UP TO$10,000 PER BILLABLE YEAR FOR THIS DISPOSAL SITE. YOU MUST LEGIBLY COMPLETE ALL RELEVANT SECTIONS OF THIS FORM OR DEP MAY RETURN THE DOCUMENT AS INCOMPLETE. IF YOU SUBMIT AN INCOMPLETE FORM,YOU MAY BE PENALIZED FOR MISSING A REQUIRED DEADLINE. Date Stamp(DEP USE ONLY:) Revised:02/10/2006 Page 3 of 3 � i Y — HOBBSBWARREN'M THE COMMONWEALTH OF MASSACHUSETTS FORM 30 C B D OF HEALTH CITY/TO N a PARTMETAa ADDRESS ADA !3YU/ 7 G,,M 5 ey`oW ]A ,�� �,,,, TELE N-E�- " AddresiLw ,1�1&rQI5) ccupan ') w- 451�vl 9,�/,, -�•� Floor partm n No. No. of Occu is OJIJr _ No.of Habitable Rooms— No.Sleeping Rooms No.dwelling or rooming units No.Stories `- ',\ Name and address of owner n,All 0.°)*( �jSZ JY1 -,� I G{A�e W��r Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Q Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress: and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Li htin : STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair I A I TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ,-; leme Uf— OMS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: 11110 ❑ 220 Fusing,Grnd.: AMP: Gen. Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den —Living Room Bedroom 1 Bedroom 2 Bedroom 3 Z Bedroom 4 Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.: Stacks, Flues Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats,Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTI EPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTI F E R " INSPECTO TITLE A.M. DATE TI E IJIJ �7r�6_ A.M. THE NEXT SCHEDULED REINSPECTION P.M. 1 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions,when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in`this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold,to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B)and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash,which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish,filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) _(K) Roof,foundation, or other structural defects that.may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway,.porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. beck c 2 Z ' �r� Parcel Detail Page 1 of 3 1V G. 6 I t Asa, rout t.r Jf, "� 1 Logged In As: Parcel Detail Thursday, Ap Parcel Lookup Parcellnfo Developer Parcel ID 216-042 Lot - Location 2440 IYANNOUGH ROAD/ROUTE132 I Pri Frontage 255 Sec Road ROUTE 6-A (W.BARN) Sec 50 --- Frontage -- - Village WEST BARNSTABLE I Fire District W BARNSTABLE Sewer Acct _,I Road Index 0781 Interactive Map Owner Info owner HAMM, THOMAS M & GREGORY P Co-owner Streetl P O BOX 13 Street2 City W BARNSTABLE State MA zip .02668 Country 'US - Land Info Acres 0.64 Use Single Fam MDL-01 -') zoning RF Nghbd 0105 Topography Level Road Paved utilities Gas,Well,Septic Location Construction Info Building 1 of 1 Year I Roof Ext 1983 Gable/Hip — ( Wood Shingle Built - Struct ----_ _ __..__ Wall ----- Effect I AC Roof p 2467 Asph/F GIs/Cm I None Area --- --- --- Cover - -- -- - Type -- - style Colonial Int 1 Drywall Bed 4 Bedrooms Wall --ry --- Rooms -- - --- -� Int Bath Model Residential JI Floor Carpet I Rooms ?_Full + 1 H �I Grade Average I Heat Hot Air Total 8 Rooms TYPe - Rooms — -- http://issql/intranet/propdata/ParcelDetail.aspx?ID=15407 4/12/2007 Parcel Detail Page 2 of 3 D.K 2Z. iAS S 34 16.�� MT Stories 2 Stories Heat Gas I Found Poured Conc. ( G� -- ---- Fuel { ation 2m i I �38 Permit History Issue Date Purpose Permit# Amount Insp Date Comments - Visit History Date Who Purpose 10/25/2005 12:00:00 AM Jason Streebel Drive by inspection only 5/2/2000 12:00:00 AM Paul Talbot Meas/Listed - Sales History Line Sale Date Owner Book/Page Sale P 1 3/31/2005 HAMM, THOMAS M & GREGORY P 19676/145 2 9/15/1984 LAVIN, DORIS R 4262/270 3 6/15/1984 LAVIN, DORIS R 4153/114 4 10/15/1980 MCNALLY, JAMES P & PM 3182/309 Assessment History Save# Year Building Value XF Value OB Value Land Value Total Parc( 1 2007 $215,800 $2,500 $0 $159,400 2 2006 $209,300 $2,700 $0 $169,500 3 2005 $191,700 $2,700 $0 $154,100 4 2004 $155,800 $2,700 $0 $92,400 ; 5 2003 $138,200 $2,700 $0 $59,000 6 2002 $138,200 $2,700 $0 $59,000 7 2001 $138,200 $2,800 $0 $59,000 8 2000 $102,700 $2,800 $0 $36,900 9 1999 $102,700 $2,800 $0 $36,900 10 1998 $102,700 $2,800 $0 $36,900 11 1997 $110,100 $0 $0 $28,700 12 1996 $110,100 $0 $0 $28,700 13 1995 $110,100 $0 $0 $28,700 14 1994 $111,100 $0 $0 $40,600 http://issql/intranet/propdata/ParcelDetail.aspx?ID=15407 4/12/2007 Parcel Detail Page 3 of 3 A15 1993 $111,100 $0 $0 $40,600 16 1992 $126,300 $0 $0 $45,100 17 1991 $122,500 $0 $0 $65,500 18 1990 $122,500 $0 $0 $65,500 19 1989 $122,500 $0 $0 $65,500 20 1988 $99,400 $0 $0 $24,000 21 1987 $99,400 $0 $0 $24,000 22 1986 $99,400 $0 $0 $24,000 Photos http://issql/intranet/propdata/ParcelDetail.aspx?ID=15407 4/12/2007 } COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AF ECEIVED Z w DEPARTMENT OF ENVIRONMENTAL PROTECTION f C MAP Z.I (� - JUN 2 12004 `o, ���~ .r-==•,-._� TOWN OF BARNSTABLE PARCEL. ` HEALTH DEPT. LOT TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 2440 IYANOUGH ROAD W.BARNSTABLE,MA 02668 Owner's Name: DORIS ROSE LAVIN Owner's Address: 38 GREENLAND CIRCLE YARMOUTH,MA 02675 Date of Inspection: 6/3/04 ri Name of Inspector: (please print) JOHN GRACI,INC. COP Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT 1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes _ Conditionally „asses _ Needs Furthe° valuation by the Local Approving Authority _ Fails Inspector's Signature: Date: 6/3/04 The system inspector shall submit a cop�of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. I,*the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. i ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 incnPctinn Fnrm 6/15/,?(1M 1 I Page 2 of I I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 2440 IYANOUGH ROAD W. BARNSTABLE, MA 02668 Owner: DORIS ROSE LAVIN Date of Inspection: 6/3/04 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: SYSTEM PASSED TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. n/a The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is'less than 20 years old is available. ND explain: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a i A 'Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 2440 IYANOUGH ROAD W.BARNSTABLE,MA 02668 Owner: DORIS ROSE LAVIN Date of Inspection: 6/3/04 C. Further Evaluation is Required by the Board of Health: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance n/a "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: n/a f Page 4 of 11 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 2440 IYANOUGH ROAD W.BARNSTABLE,MA 02668 Owner: DORIS ROSE LAVIN Date of Inspection: 6/3/04 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _ X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow _ X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped nLa. _ X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ X Any portion of a cesspool or privy is within a Zone 1 of a public well. _ X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. d `Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 2440 IYANOUGH ROAD W.BARNSTABLE,MA 02668 Owner: DORIS ROSE LAVIN Date of Inspection: 6/3/04 Check if the following have been done. You must indicate "yes" or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks`:� _ X Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the sit: inspected for signs of break out`? X _ Were all system components,excluding the SAS, located on site'? X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees, material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? X _ Was the facility owner(and occupants if different from owner).provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X _ Existing information. For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] 5 � •Page 6 of 11 f� OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 2440 IYANOUGH ROAD W.BARNSTABLE,MA 02668 Owner: DORIS ROSE LAVIN Date of Inspection: 6/3/04 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330 Number of current residents: 0 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use:(yes or no): NO Water meter readings, if available(last 2 years usage(gpd#,n-/'a Sump pump(yes or no): NO `_l Last date of occupancy: 5/1/04 COMMERCIAL/INDUSTRIAL ff Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no):NO If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 1983 PER OWNER Were sewage odors detected when arriving at the site(yes or no): NO 1 'Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2440 IYANOUGH ROAD W.BARNSTABLE,MA 02668 Owner: DORIS ROSE LAVIN Date of Inspection: 6/3/04 BUILDING SEWER(locate on site plan) Depth below grade: 14" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on cond's.tion of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X:(locate on site plan) Depth below grade: 14" Material of construction:Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: L 8' 6" H 5' '11" W 4' 10"" Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: n/a Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 18" How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL,COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP:_;locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottorr,of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a 7 `Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2440 IYANOUGH ROAD W. BARNSTABLE,MA 02668 Owner: DORIS ROSE LAVIN Date of Inspection: 6/3/04 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(expfain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level:N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: n/a Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): NO D-BOX,SNAKED THROUGH.ASBUILT IS INCORRECT PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a R `Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2440 IYANOUGH ROAD W. BARNSTABLE,MA 02668 Owner: DORIS ROSE LAVIN Date of Inspection: 6/3/04 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a l n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF FAILURE.PIT HAD 1' OF LIQUID IN IT AT TIME OF INSPECTION. STAIN LINES INDICATE PIT HAS NEVER HAD MORE THAN P OF LIQUID IN IT.BOTTOM IS AT 8 FT. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a Q "Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2440 IYANOUGH ROAD W.BARNSTABLE,MA 02668 Owner: DORIS ROSE LAVIN Date of Inspection: 6/3/04 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 07 6 - � bA �dA l�P 1� ccZg10 to I "Page 11 of 11 c OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2440 IYANOUGH ROAD W. BARNSTABLE,MA 02668 Owner: DORIS ROSE LAVIN Date of Inspection: 6/3/04 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground.water elevation: NO Obtaimd from system design plans on record-If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: HAND AUGER- 12+FT. 11 s .;7.. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH .Town..................OF........-.Barnst-able Appliration for Bhipaaal Workfi Tonfitrurtio amit Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal System at: �}SSESfiKf. .yya- ;-14" — ...............$Ol t e...132__.$._ Wuto...6k------------------------- -...__...•--....------•••..._......_..-•--•-.._._...-•--....._................._...----•--•-•----- !9/yCJ I�/t�(ation1�dlsLL/1 �7 L �g°dL/ b ���t st or Lot No. - ... --- ... -------- - W ................................................� r -----------•-•-••.Address---••---••--------•--.._..••--•••-•••- PQ Installer Address d Type of Building Size Lot._31_.Q5l---------Sq. feet U Dwelling—No. of Bedrooms........:._-- .............................Expansion Attic ( ) Garbage Grinder fio) Other—Type of Building ____________________________ No. of persons_________________.__________ Showers ( ) — Cafeteria ( ) Q' Other fixtures __________________________________ W Design Flow...............55.......................gallons per person per day. Total daily flow.....440..............................gallons. WSeptic Tank—Liquid capacity 1000gallons Length__ 1_61,__. Width__4.T_10T4 Diameter________________ Depth__ � x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-------- Diameter------ Q_I------- Depth below inlet___.6_t........... Total leaching area_.2Ej ....... ft. z Other Distribution box (X ) Dosing tank ( ) aPercolation Test Results Performed by.-CEL -e___COCd___SUx'V.ey.__Consulter'brit$date______g./1,2�f1Q_____________. ,--a Test Pit No. 1-----2--------minutes per inch Depth of Test Pit...12_1.......... Depth to ground water_nane. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Ix - ------------------------------------------------------------------------------------•--•----•--........................ 0 Description x Descri tion of Soil._Q•Q-0_-5... __ an rlOam _0 -.3 .0-12.0 med-sndt/_..�.Q1�blea_.------------------------------------------------- U goy W ROBERT ----•-•---------------------------------------•-•-•------------------------------------•------•--•-------------•---•-•---•------•------••-•-•---•---------------•--------- � -- VNature of Repairs or Alterations—Answer when applicable................................................................. CL- -•----DAYLiSR --------------------------------------------------------------------------------------••-----•-•--------•---------.._.__._..-----------------------------------------••-- ,¢ --ML/ Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in a �dl , sT� �� S0 the provisions of i?T== L p 5 of the State Sanitary Code— The undersigned further agrees not to place t operation until a Certificate of Compliance has bee issued by the board of health. Signed-. - ----•----•----•-•-- ....... Application Approved BY - ,C Date ---- ------------------------••----------•--------------•----------_-••--•--------- ---------------------------------------- Date Application Disapproved for the following reasons:---•--------------------------------------------------------------------------------•••-•--••----•-----------•-- --------------------------------------------•---------------••-------------------.--......_..-------•----------------------------------------------------------------.-.-•------------------------------ Date Permit No. ..- .�... Issued -•- Date THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) I A- DATA t ! Fxs...............` J.......... ' ;�... THE COMMONWEALTH. OF MASSACHUSETTS BOARD OF HEALTH �awr'<. ..............OF......-..Barnstable Appliratilan for Dhipoii al Works Tomitrnrtiun motif Application is hereby made for a Permit to Construct QK ) or Repair ( ) an Individual Sewage Disposal System at: , ..............Route...13a•• --$a t -•--------•--•---------- •-•--...•---•••••--......... ....a---_. ..... ..•..?---.--------------.............--- Location_Address r or Lot No. s,..X.?e.-%> f ✓ r:` �r /c ,rcl Jit,r� f3 ;ice c . ............ ................... ...•_-_••---•-•...._.....__-________....._ ...................'.......................................................... ....... ....._. Owner Address W Installer Address d . Type of Building Size Lot_31.A...5. ......... feet U Dwelling—No. of Bedrooms............ _____________________________Expansion Attic ( ) Garbage Grinder f o) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) —.Cafeteria ( ) a' Other fixtures ____________________________ _ Design Flow______________S-5........................gallons per person per day. Total daily flow-----4,1yQ...................__.___.....gallons. W Septic Tank—Liquid capacity,1 Q00gallons Length__ 6!!___ Width_.4 t_10.1s Diameter________________ Depth_-5_!Vq__- xDisposal Trench—No_ ____________________ Width......:............. Total Length.................... Total leaching area....................sq. ft. Seepage Pit No......1............ Diameter-----1.Q.______. Depth below inlet....6!.______.._. Total leaching area__26i?........sq. ft. z Other Distribution box (g ) Dosing tank ( ) Percolation Test Results Performed by-Gape...God...Survey...Consultant Mate_____91 2-1&______________ aTest Pit No. I.....R........minutes per inch Depth of Test Pit-_12............ Depth to ground water.__________-. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ x ......................................... D Description of Soil d• —Q• 14 .,_._ ---suhsII13♦a--- ...aand-r•-• �gaSN_OF J_ x ---- 3_.®- �Q. ••-••Sand---W�-•-Cobbles;....................................................... a. ••-••••---•••-•- qc UROB&T yG U Nature of Repairs or Alterations—Answer when applicable.------------------------------------------------------------------ v- ------©fl'Htf3f� C y Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in acc the provisions of'TT LE, of the State Sanitary Code—The undersigned further agrees not to place the operation until a Certificate of Compliance has be issued by the board of health. Signed.... it, Application Approved B - � ----- ------ ------------------------- a' PP PP Y --••--•••••------- Dat---••-••••••••-- Date Application Disapproved for the following reasons-----------------------------------------------------------------------------•--•-----.......................... -•-------------------------•-------------•---•----••-----•--•----------.-..-----------------------.....-- •••••••-•--•--•---••--•••••--•••••----••••-••••-••-----•••-•-•-•---•--------•---••---•••--•--• _._.. Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD) OF HEALTH `¢J/✓`• _ F ,gyp., _ P.44 t[ ............................O F..........•-......................................................................... Trrtif iratr of ( omplianrr THIS 7S TO CERTIFY, That e Ind:vid al. e jai-posal System constructed ( ) or Repaired ( ) by-••-••--•••-•••••-•-••-••••••••--•.............•••••_--- f ------- -•-•--------•-----------•-------.._..---•-•-------........-•--------•--- x f /4� ,�;A ,, F Instal/-rtu s,-.' y.",Jq>. _ r has been installed in accordance with the provisions of TITLE j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.__:: :r}__"_� :---______________ dated----------------------------------.............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT B>CCONSTRUED S A GUARANTEE THAT THE SYSTEM WIL FU CTION SATISFACTORY. r DATE..... 4 • --Y ................................................... Inspect --••--•-•-••--•••••-•••---•••-••••-•-•-----•--•------•----•--..._._....._ 41. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 2 el OF.. 1�"; r� No......................... FEE........................ Disposal orku (9-a� i�an amit Permission is hereby granted............... - -------- -- -------- ---- .............................................................. to Construct (,. ) or, RepairF(,j an,I fvidual Sewage Disposal System 6--far at No..•--••--....••••••••••••••---._..•-----••••-•-••••.................. -----------••---------------------•-------•--------•------------------------------------•--•-•-••-••......-- Street ,7 as shown on the applicatio for Disposal Works Construction Permit No.:°__:___ ______ Dated.:.._:?_.__:.'......................... •--------------------------------------------------•---------------•-----------._.__.__.. ...-•-_••--- DATE_ l -.,.. __. .. . __________________________••____........... Board of Health FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS �14 erb �, "r�l� Z '" LOCATION k SEWAGE PERMIT NO. viilACE PN�1od ( M � I N S TAL WE R'S NAME i ADDRESS • U LDER OR WN DA T E PERMIT ISSUED DAT E COMPLIANCE ISSUED j�� o �s Q�e rc �R6ric� L Q-,CAT 14 '; SEWAGE PERMIT NO. VILLAGE INSTALLER'S NAME i ADDRESS accPti Quog7G BUILDER OR OWNER J Arw►�s /`��NRi�� 0A T E P EA MIT ISSY E D — DATE C0MP.L.IANCE' ISSUED /D " a . r r, rRa� .,. ��� �, 4� o� ��� 8' � sf I, _ � �/r, p �'�. �� t i ABOCBBOIIO MAI' TEST HOLE LOGS t PARCEL : -44 f� n I) The installation dial) cort�h� with 'Title V a��J "Town of 3oard of ( � SOIL LvALuA�I 0r1 t 1 1P �• � z I lealth Regulations. �I,, WITNESS : .� 2) The installer shall verify the location of utilities, sewer inverts and septic `�� R. l I _ components prior to installation and setting base elevations. REI'ERENCE DATE: Il--� ��-� p l 11(� Lt71 PERCOLATION FEATE: Z 1�1 tom ' 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per foot. The first G --- -----�--- -- ----- — �1-�i two feet out of the d-box to the ieaching shall be level. � 31 ell �, __-_ 1 ' �_____�j_ _ _ -- \if q.1�� y' � 4) This plan is not to be utilized for property line determination nor any other '� TH- 1 TH-2 purpose other than the proposed system installation. 5) All septic components must meet Title V specifications. �0� ..•-� fl� C" - 1 ►_ lD I 6) Parking shall not be constructed over H 10 septic components. 1 1.71 1pVM � I ,y 7) The property is bounded by property corners and property lines. --�--� ,,1 1 (� lb 8 perty owner) The pro shall review design considerations to approve of total g _ o 3� design flow and number of bedrooms to be considered for design. Receipt LOCATION MAP _ ��,I� �IW of payment for the plan and installation based on the plan shall be deemed • C � approval of the design flow by the owner. 9) The existing leaching or cesspools shall be pumped and filled with material per Title V abandonment procedures. Those within the proposed SAS shall / be removed along with contaminated soil and replaced with clean sand per �► / `� / Title V specs. ,Go! (o'�;� 10)System components to be 10 feet from water line. Sewer lines crossing the water line shall be sleeved with 4 inch SC1140 PVC with ends grouted if applicable. The proposed SAS is being installed below the water service line. The line is to be sleeved as aforementioned and maintained in place. ' I S E P I C SYSTEM DESIGN I l) If a garbae grinder exists it is to be removed and is the responsibility of the / owner to ensure such:• / 12)The installer is to take caution in excavation around the gas line if such FLO'W ESTIMATE / exists. • 13)GAL/DAY Tne installer shall verify the location, quantity and elevation of the sewer BEDROOMS AT GAL/DAY/BEDROOM/ • J� I I b - �D lines exiting the dwelling"Prior to the installation. 14)This plan is representative only that a system can fit on a property meeting SEPTIC TANK _ , Title V requirements. 3��GAL/DAY x 2 DAYS -: GAL t USE I L-00 GALLON SEPTIC TA",6 I / ♦ 4(01L ABSORP`�1 ON SYSTEM` t � f. '� 5.�,vIC:F. 1-t>►�Il�i�J' i�it`aF,uq�`s�; DAViD o y SIDE AREA: V�IA� ` '1,1L MASON m d 1 BOTTOM AREA: l ��1 3 v NO.10ss o SYSTEM SECTION -_ SEPTIC H g114 _ . l . ' .5fo,I ,:::7rr d a- ) I W *I*r G 3b7et 00 /,, �, `'I GAL SEPT1,C T K HZO ! r' 7 � � h =' ALOOL :°::.5 -_ ✓ ply O� 4 m �> Ab rl t ( SITE AND SEWAGE PLAN LOCATION A N food v►� u Aw E� �W 14 g�_ v�J %�_hz - 1��►-1 -��'` PREPARED FOR : 01 o VIMP i - — -- - ._. _ SCALE: t IPtI, � _ DAV I D B . MASON ` DATE:of I i DBC ENV I RONMENITAL DESIGNS EAST SANDWICH . ` MA u • � ��► � HEALTH AGENT SOS ) y $33' 2 177 - DATE Z ,, � . � - 11-1-1_"__-'.-_.__--__'.-". I � �� -I 11.1, "I., I I I I I I I I � . I - 11 1. II I I I I I I, I i �_ � I �. - - � 7 1 1 1 1 . " I I � 1. I I i . . . I . � �I � *�I 1. � I- . I I � I � � I I � I I I I I I .. I - .� 11 � I I�-,I I I I I I� I� I- . I� .�11 I-- - I- �. . . � � .-I I I I . I I I � . I. � ,. I .' � I - . �� � I � I I .. . I . 11 . � I � � . . .I r. I- I . . � I i I - I , . " � . I.. .,: " I - . . I I I I , I � � � � . 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